Fact Sheet: Medicare Part D Extra Help Program

What is Extra Help?

Part D prescription drug coverage is available for any Medicare beneficiary. Extra Help is a program within Medicare that assists individuals with the cost of their Part D prescription drug plan. Some Medicare beneficiaries with limited resources and income are eligible for the Extra Help program.

What does Extra Help cover?

Extra Help assists eligible beneficiaries with paying for costs associated with their Medicare Part D prescription drug plan, like annual deductibles, monthly premiums and prescription co-payments or coinsurance.

How Much Will You Pay In Extra Help?

With the full Extra Help benefit in 2020, an eligible beneficiary should pay no more than $3.60 for a generic drug (or a brand-name drug treated as a generic) and $8.95 for any other brandname drug. Savings for individuals enrolled in Extra Help are estimated to be about $4,900 per year. Most people who qualify for Extra Help pay nothing, or a reduced amount, for their monthly premium and annual deductible and will pay no more than the LIS drug coverage cost limit.

Medicare enrollees who have full Medicaid coverage, get help from your state Medicaid program paying your Part D premiums, get Supplemental Security Income (SSI) benefits, or live in an institution like a nursing home should automatically qualify for Extra Help.

How to Qualify for Extra Help

Many Medicare beneficiaries qualify for Extra Help and don’t even know it. To qualify for Extra Help:
1) You must be enrolled in a Medicare Part D prescription drug plan.
2) You must reside in one of the 50 states or the District of Columbia.
3) Your annual income must be less than $18,735 for an individual or $25,365 for a married couple living together.* Even those individuals or couples with incomes exceeding the threshold may still be eligible for assistance (for example, if you or your spouse support other family members who live with you, have work-related earnings or live in Hawaii or Alaska).
4) Your resources cannot exceed $14,390 for an individual or $28,720 for a married couple who live together to receive Extra Help.* Resources include: bank accounts, stocks and bonds. Resources do not include: your home, your car, or life insurance policies.

* Note: These are the income and resource limits for 2019; these figures may change in 2020.

How to Apply for Extra Help

To apply for Extra Help, you must complete Social Security’s Application for Extra Help with
Medicare Prescription Drug Plan Costs (SSA-1020). You can apply in the following ways:

Call Social Security at 1-800-772-1213 (TTY 1-800-325-0778) to apply over the phone or to request an application; or

Apply at your local Social Security office.

Once you’ve submitted your application, Social Security will review and send a determination letter to inform you whether or not you’ve qualified. As soon as you receive your eligibility determination, you can choose a Medicare Part D prescription drug plan.

Being deemed eligible for Extra Help does not automatically enroll you in a Medicare prescription drug plan. While some beneficiaries with the full Extra Help benefit may be automatically enrolled in a Part D prescription drug plan, it is still important to follow up to ensure that you are enrolled once your Extra Help application is approved. If you are automatically enrolled but do not choose a plan for yourself, the Centers for Medicare and Medicaid Services (CMS) will randomly assign you to a plan.

What If You Don’t Qualify for Extra Help?

If you are not eligible for Extra Help, but are eligible for Medicare, you are still able to enroll in a Medicare Part D prescription drug plan. Additionally:
• Find out if your state offers help paying for drug costs, or
• Find out if the company that makes your drug offers help paying for it.

How to Ensure You’re Paying the Right Amount in Extra Help

If you think you’re paying the wrong amount, call your Medicare Part D drug plan. Your plan may ask you to provide information to help them verify if the level of Extra Help you are receiving is correct. Here is a list of documents you can use to help prove you qualify for Extra Help:

A purple notice from Medicare that says you automatically qualify for Extra Help.

A yellow or green automatic enrollment notice from Medicare.

An Extra Help “Notice of Award” from Social Security.

An orange notice from Medicare that says your copayment amount will change next year.

If you have Supplemental Security Income (SSI), you can use your award letter from Social Security as proof that you have SSI.

Medicare Savings Program

In addition to Extra Help, Medicare has a program called the Medicare Savings Program (MSP). These are state programs that help with other Medicare-associated costs (ex: Medicare Part B’s medical insurance premiums). By filling out an Extra Help application, you are automatically beginning the application process for MSP as well. Your state will contact you in order to complete the MSP application process. If you would like to opt-out of applying for MSP, there is a place to indicate that on your Extra Help application.

Further Information

For more information on Extra Help or assistance applying to the program, go to www.socialsecurity.gov/extrahelp or call Social Security at 1-800-772-1213 TTY 1-800-325-0778.

For more information on the Medicare Savings Program, Medicare Part D prescription drug plans, enrollment periods or other Medicare-related concerns, go to www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) TTY 1-877-486-2048.